Roadmap to a High-Performance Employee Health Plan

The roadmap to a high-performance employee health plan is in the shape of a 3-level pyramid.  

Level 1 – Primary care is the foundation of a high-performance employee health plan. There are virtual primary care and onsite clinics that provide care management, mental health services and health system navigation support. Primary care is paid directly by the employer and is not run through the insurance carrier.  

Level 2 – Specialty care is the middle layer and is run through the TPA or ASO carrier. The key is the plan design steers members to the highest quality specialists by offering them at a lower out-of-pocket cost, while the low-quality specialists have a higher out-of-pocket cost.  

Level 3 – Acute hospital care is at the top and direct contracting is used outside of the insurance carrier for ortho, cancer and cardiovascular care.  

This high-performance employee health plan is then surrounded by a transparent, pass-through PBM.  

The companies Serigraph and QuadMed implemented similar plans over a decade ago with tremendous success and cost savings. Specifically, Serigraph made an upfront investment of $2 million for their 1,000 employees and saved $31 million over 9 years.  

That’s a 15:1 ROI equal to savings of $3,222 per employee per year for 9 years straight. 

Just as important, Serigraph saw an improvement in employee health AND employees LOVED their health benefits.  

In fact, an employee who left Serigraph for another job gave the following feedback to HR during his exit interview: “I won’t miss working at Serigraph, but I will miss the employee health plan.” 

Lowering healthcare costs, improving employee health and improving benefits satisfaction is a solvable problem.  It already has been solved by other employers.   

It’s not a mystery. 

However, it does require action. 

The question is… are you ready to act? 

Sources: The Company That Solved Healthcare by John Torinus and Speeches by John Torinus